1. Get Connected don’t imagine the future > live it Technology Models for Building Health Information Infrastructure I John Lightfoot VP Technology Healthvision, Inc. jlightfoot@healthvision.com

2. Get Connected don’t imagine the future > live it Agenda > Value of Health Information Interoperability > How does a community get there? > Real-life RHIO example > Technology Models > Standards > Challenges for a National Model

3. Get Connected don’t imagine the future > live it Value of Healthcare Information Exchange and Interoperability (HIEI): CITL Key Findings > Standardized, encoded, electronic healthcare information exchange would: ● Save the US healthcare system $337B over a 10-year implementation period ● Save $78B in each year thereafter ● Total provider net benefit from all connections is $34B ● Net benefits to other stakeholders: - Payers $22B- Pharmacies $1B - Laboratories $13B - Public Health $0.1B - Radiology centers $8B > Dramatically reduce the administrative burden associated with manual data exchange > Decrease unnecessary utilization of duplicative laboratory and radiology tests

4. Get Connected don’t imagine the future > live it CITL HIEI Taxonomy LevelDescriptionExamples 1 Non-electronic dataPhone, US Mail 2 Machine-transportable data Fax/Email without categorization 3 Machine-organizable data Text reports, HL7 messages 4 Machine-interpretable data LOINC-based lab results from lab system; codified medication hx

5. Get Connected don’t imagine the future > live it HIEI National Net Cost-Benefit Level 2 Level 3 Level 4 $22B $24B $78B Annual Net Return after Implementation $141B -$34B $337B Net Return over 10-year Implementation Value of HIE standards is the difference between Level 3 & 4

6. Get Connected don’t imagine the future > live it 10-Year Cumulative Net Return by HIEI Level Level 1 Level 2 Level 3 Level 4 in billions

7. Get Connected don’t imagine the future > live it The Connected Healthcare Community > Patient-centric design > Disparate IT systems are unified through a shared information architecture > Collaborative Care Model > All providers have access to complete, up- to-date patient information Physicians & Staff & Staff Hospitals Pharmacies Diagnostic Labs Patients Managed Care

8. Get Connected don’t imagine the future > live it How does a community get there? Four Step Process

9. Get Connected don’t imagine the future > live it  Implementation / Integration Services  Application / ASP / Service Delivery  Connecting Hospitals, Labs, Pharmacies  Connecting Physicians  Connecting Patients  Ongoing Training & Support  Office Workflow Optimization  Benefits Analysis  Trading Partner Management  Strategic Planning  Governance  Funding Models  Information Systems Strategy  Information Systems Strategy  e-health Interoperability Platform  Implementation / Integration Services  Application / ASP / Service Delivery Phases

10. Get Connected don’t imagine the future > live it Imagine.... > Connecting 8 competing hospitals, 2 competing reference labs, and thousands of physicians and pharmacies to build an entire community’s shared patient record > Providing an entire care team (primary care physicians, specialists, nursing staff and hospital staff) access to an integrated patient record view > Viewing historical and codified lab data from multiple labs (reference, in-patient and ambulatory) > Delivering comprehensive current problem lists and allergies to the point of care > Having access to a patient’s medication history and knowledge tools that check allergy and drug to drug to reactions > Driving formulary compliance on prescriptions and lower cost substitutions for high prescribing physicians that save the community as much as $15,000 per physician per year > Providing a community infrastructure that supports EMR interoperability so that physicians with different IT systems can share relevant patient information among them > Implementing all of this within a 3–6 month timeframe

11. Get Connected don’t imagine the future > live it Reality > Taconic IPA (Mid-Hudson Valley, NY) has established an operating RHIO > 1000+ current users (400 physicians) using a shared data exchange > 4 Hospitals, 2 Reference Labs (LabCorp and Quest) connected > EMPI established to handle person identity resolution > System live and users trained within 90 days of project kickoff ● Data Exchange (Connectivity) ● CDR – Shared Patient Record ● Community Portal (Physician View) ● EMPI – Person Resolution ● eResults Software Applications ● 18 Hospital and Lab interfaces > 3 EMR vendors (Allscripts, NextGen, GE) agree to interoperability w/ CCR and HL7 Data Exchange > Contract Signed on October 1, 2004 – system live and users trained December 31, 2004.

12. Get Connected don’t imagine the future > live it “Stunning” Interoperability

13. Get Connected don’t imagine the future > live it Technology > Delivered via an ASP model > IBM servers on Intel architecture > Portal built on a Microsoft platform ● Windows Server 2000/2003 ● Internet Information Server ● SQL Server 2000 > Data exchange and routing via Cloverleaf interface engine > EMPI services provided by Eclipsys > Clinical vocabularies and libraries from IMO, Multum, Healthwise and others

14. Get Connected don’t imagine the future > live it Healthvision - Scale > 1000+ hospitals utilize servers daily > Manage a Microsoft environment of approx 250 servers > Platform database grows 12-15% per month and currently is approx 2 TB in size > Over 8 million unique patients in database > Interface Engine processes approximately 310,000 clinical transactions per day > Support 2.0 Million+ unique users/month > Over 11.7 TB per year in network traffic

15. Get Connected don’t imagine the future > live it Technology Model > Regional Clinical Data Repository > Longitudinal patient record across all systems > Reference pointers back to images and documents > Single sign-on to third party systems > CCOW support > Intelligent routing of HL7 and CCR data to EMRs > Record Locator Service to find national records > National exchange of clinical data among RHIOs

16. Get Connected don’t imagine the future > live it Clinical Advantages of a Regional CDR > Effective re-use of clinical data ● Codified data for reporting, graphing, and clinical decision support ● Ongoing surveillance Hazardous conditions Missed disease management opportunities Potential errors Adverse effects > Automatic alerts to providers ● Data from multiple sources combined ● Clinical alerting rules run across combined data

17. Get Connected don’t imagine the future > live it Clinical Advantages of a Regional CDR > Longitudinal, patient-centric view ● Multiple providers in multiple locations easily share data from multiple systems > Proven physician and staff acceptance

18. Get Connected don’t imagine the future > live it Technical Advantages of a Regional CDR > Centralized security access model for easier management of access to protected health information > Time to market ● Common data framework ● Common configuration tools ● Common implementation process ● Reusable interface libraries > System performance and reliability ● End user not waiting while multiple systems are queried ● Easily scalable with increased number of source systems and users

19. Get Connected don’t imagine the future > live it Technical Advantages of a Regional CDR > Easy to integrate new modules ● Applications leverage a common set of clinical data and system services > Not dependent on source system availability ● Easy to provide redundancy and eliminate single points of failure > Person resolution complexity ● Fully decentralized system requires matching patients across multiple systems in real time ● Allows timely human resolution of ambiguous matches

20. Get Connected don’t imagine the future > live it Technical Advantages of a Regional CDR > Standard legacy system interfaces ● HL7 and now CCR ● Takes advantage of built-in interface capabilities already built in to most clinical information systems > Centralized security model ● No need to provision multiple individual systems

21. Get Connected don’t imagine the future > live it Standards > In order to deliver interoperability, adherence to standards is key ● HL7 for registration and results exchange ● CCR for visit snapshot ● ICD9 for problems ● CPT for procedures ● NCPDP for pharmacy ● X.12 for eligibility and billing > Problem with standards is definition ● HL7 too loose ● CCR doesn’t define vocabularies

22. Get Connected don’t imagine the future > live it Healthvision Interoperability platform

23. Get Connected don’t imagine the future > live it Challenges to a national model > Scalability ● Can systems scale from a few million patients to a few hundred million? > Identity resolution ● How do you quickly resolve patient identity across systems nationally? ● Privacy concerns over a national patient identifier > Security model ● How do you know who should get access to what data on a national level?

24. Get Connected don’t imagine the future > live it Questions or Comments John Lightfoot Healthvision, Inc. jlightfoot@healthvision.com (972) 819-4353 jlightfoot@healthvision.com Thank You!